Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
The client is a multi-line managed care enterprise that serves as a major intermediary for both government-sponsored and privately insured health care programs.
Client Need
In the business end, there was no process to split the amounts into Medicare and Medicaid responsibilities for dual claims
Previously, client had to alter their claims processing in order to capture this information
In the technical end, the client was facing strict go live timeline of OSDS from state and with ongoing APD submissions
The enhancements needed to be appropriately designed and implemented without affecting each other’s timelines
Solution
Integrated dual claims split and minimum wages information into replication process for their claim submissions
APD and OSDS claim submissions processes are enhanced with implementation of logic using split amounts and minimum wages information with correction of dollar amounts at claim and claim line levels
Created processes to report errors (State rejections and submissions errors) and to notify business teams
Created workload automation for monthly resubmissions of claims based on new split amounts and minimum wages
Realized Benefits
Added value by reducing business analysis efforts through query based automated approach of notifying business team with appropriate State responses information
Manual effort of frequent analysis of state responses and resubmissions are reduced through automated reporting and resubmission processes
Code has been reused at most of the places for APD and OSDS, causing reduced development and code maintenance efforts to 50%
Tools & Technologies
Greenplum
Microsoft SQL Server 2016
IBM
Datastage
Automic
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